Measure Exception Form

Some hospitals may not have locations that meet the National Healthcare Safety Network (NHSN) criteria for CLABSI or CAUTI reporting and some hospitals may perform so few procedures requiring surveillance under the SSI measure that the data may not be meaningful for Hospital Compare or sufficiently reliable to be utilized for quality reporting purposes in a program year.

Reporting will not be required for these measures if the PPS-Exempt Cancer Hospital (PCH) performed less than a combined total of 10 colon and abdominal hysterectomy procedures in the calendar year prior to the reporting year. To indicate a measure is not being reported, a Measure Exception Form should be completed and submitted prior to the First Quarter data submission deadline for the applicable program year.